| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
561 |
248 |
$47K |
| D1110 |
Prophylaxis - adult |
1,024 |
976 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,240 |
922 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,103 |
920 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,028 |
969 |
$25K |
| D0330 |
Panoramic radiographic image |
559 |
502 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,108 |
1,063 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
628 |
619 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
984 |
847 |
$9K |
| D1120 |
Prophylaxis - child |
172 |
171 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
43 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
445 |
288 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
15 |
$1K |